 What I wanted to show now is one nasal encephalocene and then CSF rhinorea. So CSF rhinorea is something very commonly seen by each of us in our practice. So I think it would be useful to see a CSF rhinorea video. I will start with the nasal encephalocene. This is a one year old child who came with widening of the nose and blockage of the right nose. The CT and MRI showed this huge nasal encephalocene occupying the entire right side of the nose. So as soon as this we used the adult nasal endoscope because the nose was widened even though the child was one year old and you see this huge pulsating mass in the right nostril. So I started first trying to delineate whether it can be softened by pushing it. When it did not work I coagulated the surface to shrink the encephalocene a little bit but ultimately you have to open it, evacuate the contents, identify the site where the encephalocene is herniating into the sac and then pack that area. So you see the sac has been coagulated, surface of the sac has been coagulated and it has shrunk a little bit. I could use the routine bipolar because it is prolapsing quite into the anterior near and that process is faster with the standard bipolar and now you see the nostril space is seen because of the shrinkage of the encephalocene and then the middle turbinate comes into view. So the herniation is in front of the middle turbinate in the roof of the nose from the ethmoid region. If you want to go to the spinoid region you have to go here in the spino-ethmoidal recess. Many of the CSF rhino areas also come from this region of the fovea of the ethmoid where the leak occurs. So it is in front and above the middle turbinate CSF leaks and some of the encephalocene. So you have to really angulate your endoscope nearly 30-40 degrees to see the CSF leak area if you want to do when you are doing a CSF rhino area. And now the endoscope the encephalocene sac has been opened. The brain which herniates into the encephalocene sac is always atrophic and gliotic. So it can be removed unless you have to be very careful that there is no major blood vessel herniating into it. Here the opening was small it was quite anterior hence the risk of a major blood vessel herniating into the encephalocene was very low. We did not see the olfactory nerve I saw the opening and that was clearly delineated after all the contents were evacuated and I kept within the sac I did not go outside the sac. This you see the arachnoid nerve appearing and as the contents are progressively removed you suddenly start seeing the site from where the brain has herniated into the sac. So this is the continuation from the previous video where the contents have been evacuated. So I am staying within the contents of the sac and you see CSF welling out from this area that becomes more clear. So the actual huge encephalocene was herniating from this point onwards. So it becomes a relatively simpler thing to repair. So it is important when you are doing an encephalocene to know what is the width of the bony defect which is causing the encephalocene in this case the child had a very small defect. So both CT scan and MRI helps in that endeavor and of course in CSF rhino area sometimes image guidance is very helpful especially in the beginning stage and once the limits of the bony defect is determined it is very essential to do an intradural packing. If you just do an extradural packing you run the risk of displacement of this pack and recurrence of CSF rhino area. So it is very important to define the edges of the leak and then that defect is packed with fat and sealed with fibrin glue. The technique of packing the fat is it has to a component has to go intradural and then you can use fascia if required. So it should be a combined intradural extradural packing. So you see the site of the leak and this is fat packing is done. So you can see the pulsations of the fat pack if you pack too much you do not see the pulsations. So it is a careful balance between avoiding packing too much and packing too less. The wall of the sack can be excised. So whatever is protruding into the nose the wall of the sack can be excised. So this is the post-op MRI you saw the earlier MRI scan which showed a huge encephalocele here and this is the post-op MRI scan at the end of 6 months which shows that the leak has stopped and there is no mass blocking the nose. Similarly when there is a hypothalamic hematoma which is within the third ventricle the stalk is attached to the third ventricle like this. It is possible to come from the contralateral side and then dissect and cut the stalk. This patient presented with Gelastic seizures and this is the site of entry and the sectioning of the hypothalamic hematoma from the hypothalamus. I basically started using a long endoscope when you do the nasal phase and 18 centimeter endoscope is enough because you do not need an extra length. But with the shorter length the problem is this camera and the light source and the other attachments make it difficult to introduce instruments into the nose especially when you are operating in the cellar. So when you are shifting to the cellar you need a longer endoscope. And when you operate alone for example you do not have an ENT surgeon to help you with initially then the use of this endoscope holder is very useful so that you can use both your hands. Single nostril or binostril is an approach which depends on your philosophy and it is possible to do all these surgeries within a single nostril for straightforward pituitary tumors. These are the instruments all the instruments unlike in the transpenoidal, routine transpenoidal, transnasal transpenoidal instruments you require bayonetal instruments. Here all instruments are straight examples of pituitary adenomas operated pre-op scans and this is the post-op scan showing preservation of the pituitary stalk. What is very important is recognition of the normal pituitary. The normal pituitary when you use a high definition camera the images which you saw they all are based on high definition images. So high definition camera is quite expensive most of you may not be able to purchase a high definition camera, a low definition camera may be used. In such a situation when you see the arachnoid which is coated with a thin whitish layer that is the normal pituitary even if you do not see. So you do not have to scrape anything getting stuck to the arachnoid. What is stuck to the arachnoid do not forcefully remove it. What is pituitary tumor will come out with gentle traction. So the normal pituitary gland will be stuck to the arachnoid. As the arachnoid progressively descends you see this thin whitish layer stuck to the pituitary gland leave it behind. So that is what will preserve the normal pituitary gland. In micro adenomas it is a different story you see the normal gland in the beginning itself. This again a large pituitary adenoma but again you notice there is no sideward extension into the cavernous sinus or supracellar extension to the side. So this is important when you make a case selection in the beginning. Why is it important the intracranial pressure pushes the tumor down as you progressively remove the tumor. That does not happen with a parascellar extension or an intradural lateral extension. That progressive herniation of the tumor downwards does not occur when it is not a straight forward tumor with straight up supracellar extension. And that is very important and another step which is very important in pituitary tumor surgeries you should observe how the arachnoid is dissecting descending down. When you have removed enough of the tumor in stages from the sides first posteriorly and then go to the anterior and superior portion the arachnoid progressively the diaphragm and the arachnoid progressively descend down. Then it is an asymmetric descent you see the arachnoid on one side you do not see the arachnoid on other side that means surely there is tumor which is left behind. So the post-op scan shows even with large tumors like this the pituitary stalk is preserved and the tumor is completely removed and the optic nerve is decompressed. Acromegally with as much smaller functioning adenoma the post-op scan showing removal of the tumor and the preservation of the pituitary stalk and the normal pituitary gland. So this is the case of CSF ranoria from the phobia in the arachnoid. So as I said the CSF leaks from high up in the nasal roof anteriorly. So you need to use this cotton patties soaked with adrenaline to shrink the mucosa and create the space to go in there. Otherwise you will have swollen mucosa which obstructs your view and also starts bleeding quite early. So now we will see something which I use regularly in CSF ranorias. I use 0.1 ml of 20% fluorescent in 50 ml to 100 ml of saline and inject it intrathecally when I begin the procedure. So this is quite useful in tracing the leak because most of the time it may occur through ethmoid air cells. So as soon as you identify the leak and if you pack that area if you pack the ethmoid this will definitely result in a recurrence of CSF leak. So you need to drill out those ethmoid air cells and reach to the site of the leak like I showed in the encephalocele case. So that is the most important step you have to identify the leak from the anti-cranial fossa floor proper not from the ethmoid air cells. So when the ethmoid air cells are removed you identify the site of the leak. So this is the area where the ethmoidctomy has been done and then you chase this fluorescent leak towards the site of the leak. What is the problem if you inject it twice? Suppose the leak is profuse and all the fluorescent leaks out. Can you give a second injection of fluorescent? The biggest problem with fluorescent is it is highly seizureogenic. So you cannot exceed the 0.1 ml dose which is given intrathecally. So you can inject it only once. If you need more you have to produce an artificial increase in the leak you can just inject 50 or 100 ml of mosa line to aid in identifying the site of the leak. So the technique used in repairing this leak is again you have to drill the bone till you identify the site of the leak. Clearly define the edges of the leak, do an intradural packing with fat and fascia and then apply a fibrin glue. So still some air cells are there which prevent correct identification of the site of the leak. And after the correct identification of the site of the leak fat is packed into that gap to achieve both intradural and extradural packing. Apply fibrin glue and then you can apply a layer of fascia if you want to buttress the fat. And when I operate for CSF leaks I tend to leave the lumbar drain for 24 hours at least and pack one nostril with meroseal so that the child when it cries the ICP the raising ICP does not force the fat down.